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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003936
Report Date: 04/06/2022
Date Signed: 04/06/2022 04:55:58 PM

Document Has Been Signed on 04/06/2022 04:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:TENDER HOME SENIOR CAREFACILITY NUMBER:
347003936
ADMINISTRATOR:MARINOVA, VALENTINAFACILITY TYPE:
740
ADDRESS:3499 PONZI COURTTELEPHONE:
(916) 851-1888
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 6CENSUS: 6DATE:
04/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Valentina MarinovaTIME COMPLETED:
05:00 PM
NARRATIVE
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On 4/6/22 at 2:00pm Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management inspection to address deficiencies observed while at the facility for an unrelated complaint investigation.

LPA arrived at the facility and was greeted by a staff member not wearing a mask. LPA asked if staff had a mask and if she could please put one on. LPA observed staff put a mask around her wrist and continue to provide support and assistance to residents despite LPAs request. LPA was later greeted by the facility Administrator who quickly donned a mask when entering the facility. LPA informed Administrator of LPAs observations and Administrator had a discussion with staff who proceeded to wear a mask for the duration of LPAs inspection.

The following deficiency are cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/06/2022 04:55 PM - It Cannot Be Edited


Created By: Kevin Gould On 04/06/2022 at 04:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: TENDER HOME SENIOR CARE
FACILITY NUMBER: 347003936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/07/2022
Section Cited
CCR
87468.1(a)(2)

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Personal Rights of Residents in All Facilities: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by, on 4/6/22 licensee did not ensure the personal rights of persons in care to safe and healthful accommodations and engaged in conduct inimical to the
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Licensee will submit a written plan of correction stating that all staff are required to wear a facemask and the steps the facility will take to ensure the mask requirement is adhered to. Licensee understands that another citation will result in an immediate civil penalty.
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health, welfare, and safety of persons in care, in that facility staff Tamaka Holder did not wear face coverings while in the facility, as required by the Order of the State Public Health Officer dated June 11, 2021 requiring compliance with CDPH Guidance for the Use of Face Coverings, and as required by COVID-19 Prevention Emergency Temporary Standards (ETS) at Title 8, CCR section 3205, and an individual mask exemption did not apply.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022


LIC809 (FAS) - (06/04)
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